Macrodislocation of cardiac pacemaker electrodes prior to surgery for renal tumour

Navarro-Suay, R.; López-Soberón, E.; Álvarez-Antón, S.; Puchades-Rincón de Arellano, R.

doi:10.1016/j.redare.2018.01.012

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(B) Chest radiograph showing displacement of the electrode, which is coiled around the device (Reel syndrome)." ] ] ] "textoCompleto" => "Reel syndrome is characterised by rotation of the pacemaker generator on its transverse axis with subsequent coiling of the leads around the generator. It differs from Twiddler's syndrome, which involves coiling of the pacemaker lead due to rotation of the pacemaker generator on its long axis, and is more often associated with twisting or fracture of the leads.<a class="elsevierStyleCrossRefs" href="#bib0030">1–3</a>It may go unnoticed, but usually manifests with dizziness, syncope, dyspnoea or ECG abnormalities. Chest radiography is the diagnostic method of choice, and treatment consists of reimplantation of the device with adequate fascial fixation and periodic follow-ups.<a class="elsevierStyleCrossRefs" href="#bib0045">4,5</a>We report the case of an 82-year-old man with a history of hypertension, type 2 diabetes mellitus, dyslipidemia, hypothyroidism, obesity, chronic ischaemic heart disease with two stents, residual ejection fraction of 45%, and slow atrial fibrillation. The latter was corrected with uneventful implantation of a VVI pacemaker 1 month previously with good radiographic follow-up (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) prior to scheduled right nephrectomy following diagnosis of a kidney tumour. The patient was receiving chronic acetylsalicylic acid, metformin, atorvastatin, bisoprolol, levotyrosine and amiodarone therapy.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>On the day of surgery, during the anaesthesiology checklist performed in the operating room, the patient reported “involuntary” pulsating movements in the abdomen accompanied by general malaise and dyspnoea on mild exertion that he associated with the pacemaker.After taking his clinical history and performing an ECG and a chest radiograph, we observed that the implanted pacemaker had rotated forcing the electrode to migrate from the right ventricle to the brachiocephalic artery, in the proximity of the left phrenic nerve (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).The pacemaker was immediately reimplanted under local anaesthesia and sedation, and correct positioning was confirmed on chest radiography. The patient ultimately declined surgery and instead received conservative treatment with periodic follow-up by the Urology and Cardiology Services.Some studies have observed intraoperative pacemaker- and ICD-related problems in 10% of users of these devices. There are even reports of fatalities thought to be related to these devices, in which inadequate preoperative evaluation and preparation could have played a major role.<a class="elsevierStyleCrossRef" href="#bib0050">5</a>The factors associated with Reel syndrome are a large pacemaker pocket, elderly patients with mental illnesses (who may repeatedly manipulate the device), female gender (apparently due to hypermobility of the skin) and obesity.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> These factors facilitate rotation of the pacemaker, and can lead to retraction of the electrodes.During the pre-operative evaluation of a patient with newly implanted pacemaker it is essential to ask about the onset of new symptoms since implantation of the device, and to assess the integrity and location of the electrodes on chest radiograph.<a class="elsevierStyleCrossRef" href="#bib0050">5</a> A pre-operative chest X-ray should be ordered in all patients with a pacemaker, or at least in those who have symptoms suggestive of pacemaker malfunction.In our case, despite correct implantation of the device, the generator had gradually rotated on its transverse axis. The patient presented several predisposing factors (obesity and advanced age), and his symptoms, which appeared a few weeks after implantation, could be related to aberrant stimulation of the phrenic nerve by the retracted electrode. This highlights the importance of the anaesthesiology evaluation and pre-surgery checklist, which in this case was led to the diagnostic suspicion that was later confirmed by chest X-ray. The recommended treatment was followed in this case, that is, reimplantation and correct fixation of the electrode.Early detection and treatment of Reel syndrome is essential to avoid perioperative complications secondary to pacemaker dysfunction. Diagnosis of this syndrome is a multidisciplinary task, and this teamwork is essential during the preoperative period." 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(B) Chest radiograph showing displacement of the electrode, which is coiled around the device (Reel syndrome)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Síndrome de reel: una variante del síndrome de twiddler" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Echevarri" 1 => "A.M. Barón" 2 => "J.C. García" 3 => "J.D. 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Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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